A 15-year-old, a positive screening item, and a father who does not believe in depression
A 15-year-old girl attends with a three-month history of low mood, early waking and falling grades. She was in the top set last year and is now in the bottom set. She scores 16 on the PHQ-A; on item 9 she endorses 'several days' of thoughts that she would be better off dead over the past two weeks. She has no plan, no intent, no previous attempt, and no access to firearms; medicines at home are kept in a locked cabinet. Her mother, who is present, wants 'a pill to fix it'. Her father is not present and has said in the past that 'depression is not a real illness'. The girl asks you not to tell her father. There is no substance use, she is not sexually active, weight is stable, and full blood count and thyroid function are normal.
1. How do you assess risk and handle confidentiality at this visit?
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Risk assessment is a structured conversation, not a score. Cover: frequency and content of the thoughts (passive 'better off dead' versus active ideation), any plan, any intent, access to means, previous attempts or self-harm, hopelessness, psychotic symptoms, substance use, bullying or abuse, and protective factors - a supportive mother, engagement with school, willingness to talk. The PHQ-A item 9 is a screening flag, not a verdict: a positive answer mandates assessment, not automatic admission.
On this picture she has passive ideation without plan, intent or means, no prior attempt, good protective factors and she is help-seeking. That is low-to-moderate risk: safety planning and urgent outpatient follow-up, not emergency detention. If she had a plan with access to means, or intent, she would need same-day mental health assessment.
Confidentiality: explain the ground rules at the start - that what she says stays private unless there is a risk to her life, a risk to someone else, or a safeguarding concern. Her request not to tell her father is reasonable and should be honoured where possible. Negotiate: ask whom she would want informed if things worsened, and agree that her mother will be part of the safety plan. Her father does not need the clinical details; he does need to know enough to keep her safe, and the conversation about his views is better had separately, framed around her functioning rather than her diagnosis. Document the capacity discussion, what was disclosed and to whom, and note that as a minor she will need parental consent for treatment and her assent.
2. How would you treat her, and what follow-up and safety monitoring would you arrange?
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Psychological therapy plus an SSRI. For moderate-to-severe adolescent depression, the strongest evidence is for fluoxetine combined with cognitive behavioural therapy or interpersonal therapy. Therapy alone is reasonable for mild depression; here the functional decline and severity justify medication with therapy, not one or the other.
Prescribe: fluoxetine 10 mg daily for the first week, then 20 mg daily. It is licensed from age 8 and has the best paediatric evidence. Explain that benefit takes 4–6 weeks and that the first two weeks may bring restlessness or nausea before improvement.
Monitor actively: review face-to-face weekly for 4 weeks, then every 2 weeks until 12 weeks, then at longer intervals. Ask specifically about agitation, akathisia, sleep, impulsivity and suicidal thoughts at every contact - the highest-risk window is the first 4 weeks and after any dose change. Check adherence and ask about alcohol and drugs.
Safety plan: written crisis numbers, identification of two trusted adults, means restriction already in place, and an agreement that she will tell someone if thoughts worsen. Suggested steps if things deteriorate: contact the clinic the same day.
Wider plan: involve the school only with her consent; address sleep hygiene; see the parents together to discuss family conflict; screen for bullying, exam stress and any safeguarding concern. If there is no response after 6–8 weeks at adequate dose with confirmed adherence, re-examine the diagnosis, then consider increasing to 40 mg or switching.
3. Her mother asks whether the antidepressant will make her daughter suicidal, having seen a warning on the internet. How do you explain the evidence?
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Answer it directly, because a half-answer here will lead to the medication being stopped in secret.
What the warning says: the 2004 boxed warning came from pooled short-term trials in children and adolescents. Suicidal thinking and behaviour were reported more often on active drug than on placebo - roughly 4% versus 2%. Taken at face value that is an absolute increase of about 2 percentage points, a number needed to harm of around 50 for a suicidality-related event, and there were no completed suicides in those trials. Other pooled analyses produce wider and less alarming ranges, depending on how broadly the outcome is defined. The events were mostly ideation, not attempts.
Put it beside the benefit: the number needed to treat for depression in the same literature is around 10. In other words, many more young people benefit than are harmed, but the harm is real and concentrated early.
Say what this means in practice: the risk window is the first 4 weeks and after dose changes, which is exactly when we will be seeing her weekly and asking directly about suicidal thoughts. Untreated adolescent depression carries its own suicide risk, and there is evidence that youth suicide rates rose during periods when antidepressant prescribing fell after the warning. So the warning is an argument for close monitoring, not for avoiding treatment. Offer written information and a follow-up appointment for the mother to ask more questions.